The crippling effects of a cyberattack at an academic level 1 trauma center: An orthopedic perspective.

INTRODUCTION: Malicious cyberattacks are increasing in frequency and severity with healthcare institutions spending an average of over 10 million dollars to resolve the consequences of healthcare data breaches. This cost does not include the effect of a downtime event should a healthcare system electronic medical record (EMR) lose functionality. An Academic Level 1 trauma center suffered a cyberattack resulting in a total EMR downtime of 25 days. Orthopedic operative time was used as a surrogate for OR functionality during the event and a framework with specific examples is presented to promote rapid adaptation during downtime events. METHODS: Operative time losses were identified by calculating a running average of weekday total in room operative time during a total downtime event secondary to a cyberattack. This data was compared to week-of-the-year matched data from the year prior and the year after the attack. A framework for creating adaptations to a total downtime event was created by repeatedly interviewing different provider groups and identifying how they adjusted care to the challenges faced. RESULTS: Total weekday in room operative time during the attack decreased by 53.4% ± 12.2% and 53.2% ± 14.9% when comparing the matched period one year prior and one year after, respectively. Immediate challenges to patient care were identified by small groups of highly motivated individuals, with self-assigned agile teams formed. These teams sequenced system processes, identified failure points, and created real-time solutions. A frequently updated EMR backup mirror and hospital disaster insurance were crucial for mitigating the impact of the cyberattack. CONCLUSIONS: Cyberattacks are expensive and their downstream effects, including downtime events, can be crippling. Agile team formation, process sequencing, and understanding EMR backup times are tactics used to combat the challenges of a prolonged total downtime event. LEVEL OF EVIDENCE: Level III retrospective cohort.

Severe Lacerations in Alpine Ski Racing: A Case Series and Review of the Literature.

STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4C.

Important Factors for Retrograde Nailing Through Total Knee Arthroplasty: A Cadaveric Study.

OBJECTIVES: Evaluate how total knee arthroplasty (TKA) implant design, femoral component size, and preoperative knee range of motion affect retrograde femoral nailing. METHODS: Cadaveric specimens were prepared for TKA with a single radius (SR) or medial pivot (MP) design and tested with cruciate retaining (CR), cruciate substituting (CS), and posterior stabilizing (PS) 9-mm liners. Knee extension identified the minimum flexion required to pass an opening reamer without impinging on TKA components. The angle between the reamer path and the femoral shaft was calculated from lateral fluoroscopic images. RESULTS: In SR TKA, the average flexion required was 70, 71, and 82 degrees for CR, CS, and PS, respectively. The required flexion in PS was significantly greater (P = 0.03). In MP TKA, the average flexion required was 74, 84, and 123 degrees for CR, CS, and PS, respectively. The required flexion was significantly greater in CS and PS designs (P < 0.0001). Femoral component size did not affect the minimum flexion required. The entry reamer resulted in 9.2 (SR) and 12.5 (MP) degrees of apex anterior deviation. CONCLUSIONS: When performing retrograde nailing through either of these TKA designs with a 12-mm opening reamer, at least 70 degrees of knee flexion is required to avoid damage to the polyethylene liner or femoral component. PS implants require significantly more flexion with both TKA designs. Femoral component size did not affect the flexion requirement. Approximately a 10-degree deviation exists between the reamer path and femoral shaft.

Alpine Ski Racing Injuries.

CONTEXT: This article reviews the epidemiology of alpine ski racing-related injuries, risk factors, mechanisms of injury, and injury prevention strategies. EVIDENCE ACQUISITION: Pertinent literature from peer-reviewed publications from 1976 through 2018. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: The rate of injury in alpine ski racing is high. In general, knee injuries are the most common, with anterior cruciate ligament (ACL) disruptions being the most significant in terms of time loss from sport. Three specific mechanisms of ACL injury in alpine ski racers have recently been described (slip-catch, dynamic snowplow, and landing back-weighted). In contrast to other sports, female ski racers are not clearly at greater risk for ACL injury, especially at the highest level of competition. A high percentage of ski racers are able to return to their previous level of competition after ACL injury. Risk factors for injury and methods of injury prevention have been proposed; however, the rate of injury, particularly ACL injuries, has not decreased significantly. CONCLUSION: Alpine ski racing has a high injury rate. ACL injuries in particular remain problematic. Further study is needed to identify modifiable risk factors and implementation of injury prevention strategies.

A semi-quantitative technique to assess excursion of the flexor hallucis longus.

BACKGROUND: Recent research indicates that restriction in excursion of flexor hallucis longus (FHL) contributes to hallux rigidus development. As described in the literature, clinical evaluation of FHL excursion has poor interobserver reliability. A simple, inexpensive, easily used FHL relative excursion measurement device was developed and tested. METHODS: 64 subjects were enrolled with shoe size, height, weight, BMI, and age compared. Using a footplate and series of mechanical wedges, maximum ankle dorsiflexion was measured with the great toe in 15°, 30°, and 45° of dorsiflexion. RESULTS: Ankle dorsiflexion decrease with progressive hallux dorsiflexion increase was statistically significant with a linear correlation (r2=.814 p<.001) and was not statistically related to shoe size, height, weight, BMI, or age. CONCLUSIONS: This technique provides consistent assessment of the limitation to ankle dorsiflexion incurred by decreased FHL excursion, establishing groundwork for future studies to assess the relationship between diminished FHL excursion and FHL pathology.